VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lightbridge Academy of Manassas
9855 Liberia Avenue
Manassas, VA 20110
(703) 986-3696

Current Inspector: Shawanda Henderson (540) 216-1434

Inspection Date: July 8, 2024

Complaint Related: No

Areas Reviewed:

8VAC20-780 Administration. 8VAC20-780 Staff Qualifications and Training. 8VAC20-780 Physical Plant. 8VAC20-780 Staffing and Supervision. 8VAC20-780 Programs. 8VAC20-780 Special Care Provisions and Emergencies. 8VAC20-780 Special Services. 8VAC20-770 Background Checks 22.1 Background Checks Code, Carbon Monoxide

Comments:

An unannounced renewal inspection was conducted on 7/8/2024 from 9:59am to 12:13pm with the director. There were 25 children in care, ranging in age from 2 months to 8-years-old, supervised by 10 staff. The children were observed doing tummy time, playing on the playground and playing with age-appropriate toys. 5 child records and 4 staff records were reviewed. The center has 3 staff with current certification in CPR and First Aid, and 4 staff trained in Daily Health Observation. 1 medication and authorization form were reviewed, and the center has 2 staff current in Medication Administration Training (MAT). Required postings were observed. The attendance, menu, allergy list, and emergency drill logs were reviewed. The first aid kit, flashlight, and battery-operated radio were observed. The most recent Fire Inspection on file was dated 12/15/2023 and the most recent Health Inspection on file was dated 1/12/2024. If you have questions regarding this inspection, please contact the Licensing Inspector, Shawanda Henderson, at 540-216-1434 or Shawanda.Henderson@doe.virginia.gov. Please complete the "Plan of Correction" and "Date to be Corrected" areas on the Violation Notice for each violation cited and return to me by close of business on 07/24/2024. Plans of correction should include steps to correct the noncompliance with the standard, and measures to prevent the noncompliance from occurring again.

Violations:

Standard #:	8VAC20-780-40-E
Description:	Based on observation and staff interview, the center failed to ensure the center's activities, services, and facilities were in compliance with these the center's own policies and procedures that are required by the standards, and the terms of the current license issued by the department. Evidence: There were 3 children, ages 2 months, 4 months, and 5 months, enrolled in the program. The facility is currently licensed to provide children 6 months through 12 years old.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-60-A
Description:	Based on review of 5 child records, the Center did not ensure they obtain all of the required documentation for child records. Evidence: In the records for Child #1, #2, #3, #4, there were no work telephone numbers documented for both parents.
Plan of Correction:	Create a checklist of all required documentation for child records and ensure it is provided to parents upon enrollment. Designate a staff member to verify that all required documents are complete and on file before a child is admitted to the center. Regularly audit child records to ensure ongoing compliance and follow up with parents if any documentation is missing or needs updating. Implement a secure and organized filing system to maintain and easily access all child records.
Standard #:	8VAC20-780-70
Description:	Based on review of five staff records, the center did not obtain all of the required documentation for staff records. Evidence:The center did not have documentation for Staff #1 and Staff #2 that two or more references as to character and reputation as well as competency were checked before employment.The center did not have documentation for Staff #1 that they possess the education and experience required by the job position.
Plan of Correction:	Develop a comprehensive checklist of all required documentation for staff records, including education and experience verification. Implement a thorough hiring process that ensures all necessary documents are obtained and verified before a new staff member begins work. Assign a staff member to be responsible for verifying and maintaining complete and up-to-date staff records. Conduct regular reviews and audits of staff records to ensure ongoing compliance with documentation requirements.
Standard #:	8VAC20-780-80-A
Description:	Based on review of the written attendance record and interview with staff, the center did not ensure they maintained a written record of daily attendance for each group of children documenting the arrival and departure of each child in care as it occurs. Evidence: During the inspection of the Mobile Infants Classroom, there were 4 children present, but the written record kept virtually only had 3 children present.
Plan of Correction:	Implement a standardized daily attendance log for each group of children. Train all staff in the importance of documenting arrival and departure times as they occur. Conduct periodic audits to ensure compliance and address any lapses promptly. Use digital app designed for childcare attendance tracking to minimize errors.
Standard #:	8VAC20-780-280-B
Description:	Based on observation, the center did not ensure that hazardous substances such as cleaning materials were kept in a locked place using a safe locking method that prevents access by children. Evidence: In the younger preschool and older preschool classrooms, there were cleaning agents labeled bleach water, Lysol water and Windex water in unlocked upper cabinets.
Plan of Correction:	Install lockable storage cabinets for all hazardous substances in every area where they are used or stored. Develop and implement a hazardous materials policy that includes detailed procedures for safe storage and access control. Train staff on the updated hazardous materials policy and the importance of keeping these substances locked away. Perform regular audits to ensure hazardous substances are stored securely and staff are following procedures. Post visual reminders about the importance of locking up hazardous substances in areas where they are used or stored.
Standard #:	8VAC20-780-340-F
Description:	Based on staff interviews and documentation review, the center did not ensure that children under 10 years of age always be within actual sight and sound supervision of staff. Evidence: Documentation was discovered in a staff file that documented a child aged 3 years old in the Yellow Ducks classroom, was left in the classroom for approximately 30-40 seconds during a fire drill. Director stated teachers were written up for the incident and retrained.
Plan of Correction:	Conduct a training session for staff on the importance of maintaining sight and sound supervision of children under 10 years old. Develop a supervision policy that clearly outlines the requirement for staff to be able to see and hear children at all times. Implement regular monitoring and spot checks to ensure staff are adhering to supervision policies. Use staffing plans that ensure adequate staff-to-child ratios, enabling staff to provide effective supervision. Place visual aids and reminders in classrooms and play areas to reinforce the importance of sight and sound supervision.
Standard #:	8VAC20-780-510-L
Description:	Based on observation, the center did not ensure that medication be kept in a locked place using a safe locking method that prevents access by children. Evidence: In the older preschool classroom, there was an unlocked bookbag, hooked onto a cabinet with an Epi-Pen that was just inside of a clear plastic bag.
Plan of Correction:	Install secure, lockable storage units specifically for medication in all areas where medication is stored. Review and update the medication storage policy to include specific instructions on using the locking mechanisms. Train all staff on the updated medication storage procedures and the importance of keeping medication locked away. Conduct regular checks to ensure medication is stored correctly and securely. Document each instance of medication storage and access, ensuring compliance with the locking policy.
Standard #:	8VAC20-780-550-D
Description:	Based on review of documentation and staff interview, the center did not ensure they implement a monthly practice evacuation drill. Evidence: There was no documentation for evacuation drills for May 2024 and director stated the drill was not completed.
Plan of Correction:	Develop a schedule for monthly evacuation drills and ensure it is communicated to all staff. Assign a staff member to oversee the organization and execution of these drills. Document each drill, noting the date, time, and any observations or areas for improvement. Review the evacuation procedures regularly with staff and make necessary adjustments based on drill outcomes.